THE CONTINUUM OF APPLICATIONS

The many applications of clinical performance data are illustrated in Figure 8-1. To the left of the spectrum are applications used by public-sector legal and regulatory bodies that are intended to hold health care professionals and organizations accountable (e.g., professional and institutional licensure and legal liability). To the right of the spectrum are applications that focus on learning, both for organizations and for professionals. The feedback of performance data to clinicians for continuing education purposes falls into this category, as does the redesign of care processes by health care organizations based on analysis of data collected in near-miss and adverse event reporting systems. Falling between these two extremes are applications intended to encourage health care providers to strive for excellence by rewarding those who achieve the highest levels of performance with higher payments and greater demand for their services.

Virtually all applications of clinical performance data are intended to produce improvements in safety and quality. However, their immediate aims—accountability, incentives, and system redesign—are quite different.

Aim defines the system—W. E. Deming (1988)

Accountability

Health care policy makers have long argued that there is an inherent imbalance in access to and understanding of health care information between health care providers and health care consumers (Arrow, 1963; Haas-Wilson, 2001; Robinson, 2001). To help redress this imbalance, health care overseers—federal, state, and county governments; health professional groups; and other patient representatives—have sought to guarantee a minimum level of health care delivery performance on behalf of the general health-consuming public. In recent years, some consumer-driven approaches have been adopted, such as state-level reporting of serious medical errors and the publication of health outcome data.

Health care overseers have carried out their accountability role through licensing programs for health care professionals and certification and accreditation programs for provider institutions and health plans. Traditionally, these oversight processes have focused on the establishment of “market entry” requirements (e.g., medical doctors must graduate from an accred-



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